P - 48032.
,
Building
Inspections
763-572-3604
763-502-4977 FAX
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SITE ADDRESS _
THIS APPLICANT IS:
PI20PERTY
OWNER/
TENANT
CONTi2AC'I'OR
SUBMIT A COPY OF
YOUR. STATB
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
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�����l�t'�'�� APP����'�'���t
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EFFECTIVE 7-1-2010
YOUR MAII, ADDRESS
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❑ OWNER C�EONTRACTOR
CITY
Permit No.:
Received By:
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STA
STATE LICENSE # �+namp�on r�urr �U�► �y EXP DATE �d`" � !' � %
STATE BOND #_��� oc� i�A f1 EXP DATE
�nx�ss: ��n n�dd Rd. crrY STATE ZIP,
PHONE Eagan MN 55123 F�
TYPE OF WORK: I � ��'
FAMII,Y ❑ TWO FAMILY ❑ TOWNHOUSE
DETAILED DESCRIPTION OF WORK
�REPLACEMENT
FEES ARE BASED ON $10.00 PER FIXT[TRE, EXCEPT WHERE NOTED. FUl'TURES: (II�TDICATE TOTAL NUMBER OF EACH BELOW). MINTMiJM FEE
$35.50.
BATH SINK/LAV FLOOR DRAINS SHOWER WATER PIPING
BATHTUB GAS PIPING (NEED CITY LIC) SWIMIvIING POOL _ WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK � WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY. TRAY WATER HEATER ($35) FOR ffZRIGATION
WATER METER _ OTHER
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THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTII. PROCESSED
I hereby apply for a plumbing permit an�I.acknowled'ge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes o the City of ridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permi nd w is not to start without a permit on site; that the work will be in accordance
with the approved plan in the case o ork whi re ' vi w and appro�(al of plans. )
SIGNATURE OF APPLICANT AME JC�1./VY�S����ATE �� J!� I�
APPROVAL INSPECTORS SIGNAT �\ ( /
City of Fridley
uald'ang Inspections Depariment
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977
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